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Do mental health mobile apps work: evidence and

recommendations for designing high-efficacy mental health
mobile apps
Pooja Chandrashekar

School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
Correspondence to: Pooja Chandrashekar. School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138,
USA. Email: pchandrashekar@college.harvard.edu.

Received: 19 February 2018; Accepted: 28 February 2018; Published: 23 March 2018.

doi: 10.21037/mhealth.2018.03.02
View this article at: http://dx.doi.org/10.21037/mhealth.2018.03.02

Smartphone-based apps may expand access to
mental health treatment
Smartphone-based mental health apps represent a unique
opportunity to expand the availability and quality of mental
health treatment. The number of mobile health (mHealth)
apps focused on mental health has rapidly increased;
a 2015 World Health Organization (WHO) survey of
15,000 mHealth apps revealed that 29% focus on mental
health diagnosis, treatment, or support (1). Additionally,
public health organizations like the UK’s National Health
Service (NHS) and the U.S. National Institute of Mental
Health (NIMH) have pointed to mental health apps as
cost-effective and scalable solutions to addressing the
mental health treatment gap. But though the ubiquity of
smartphones is well-poised to address the mental health
provider shortage, the efficacy of mental health apps
remains contested (2). As mental health apps are increasingly
prescribed to supplement psychiatric treatment and help
patients self-manage their mental health conditions, it is key
to understand (I) whether, and which, mental health apps
have proved effective, and (II) what makes a mental health
app effective. Here, we argue that mental health apps do have
value in providing psychological treatment, and present four
recommendations for high-efficacy mental health apps.
Why apps: the utility of mental health apps for
psychological treatment
Mental health apps target a broad range of psychological
disorders and vary in design and functionality. NIMH
classifies mental health apps into six categories based on
functionality: self-management, cognition improvement,
skills-training, social support, symptom tracking, and
passive data collection (3). Mental health apps span all
stages of clinical care provision, including immediate crisis
intervention, prevention, diagnosis, primary treatment,
supplement to in-person therapy, and post-treatment
condition management (4). Mobile apps are a good choice
for psychological treatment delivery compared to other
platforms due to (I) ease of habit, (II) low effort expectancy,
and (III) high hedonic motivation (2,5).
Do they work: evidence for using mental health
apps for treatment
Though evidence supports the use of smartphone-based
apps as a vehicle for mental health treatment delivery,
there remains debate around whether these apps have
demonstrated high efficacy (3). This is due to both the lack
of evidence-based mobile apps available on the market,
and the lack of studies that bring together the disorder-
specific silos of evidence that do exist. To show that the
efficacy of evidence-based mobile apps is comparable to
traditional psychiatric treatment, we analyze the efficacy
of smartphone-based treatments for three psychological
disorders with high 12-month global prevalence rates:
depression, anxiety, and schizophrenia.
Depression
Depression treatment options may not result in complete

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alleviation of symptoms, and often fail to address post-
treatment subclinical or residual depression symptoms.
Mobile apps that use cognitive behavioral therapy (CBT),
mindfulness training, mood monitoring, and cognitive
skills training to treat depressive symptoms are gaining
momentum. A meta-analysis of 18 randomized controlled
trials (RCTs) covering 22 mobile apps revealed that using
apps to alleviate symptoms and self-manage depression
significantly reduced patients’ depressive symptoms
compared to control conditions (g=0.38, P<0.001). They
also found that smartphone-based therapies yield the
greatest benefits for individuals with mild to moderate,
rather than major, depression (6).
Anxiety
Though clinical evidence suggests that relaxation training,
CBT, and mindfulness can reduce anxiety symptoms, access
to these interventions is limited by cost and availability.
Using mobile apps to deliver these interventions has thus
garnered attention as a supplement to in-person therapy
and a mechanism to treat sub-clinical anxiety conditions
that may lie below the threshold for anxiety disorder
treatment (7). A meta-analysis of nine RCTs that evaluated
the effects of smartphone-delivered interventions on
symptoms of subclinical and diagnosed anxiety disorders
revealed that users experienced reductions in total anxiety
after using anxiety treatment apps (g=0.33, P<0.001).
Additionally, anxiety-focused mobile apps delivered the
greatest reductions in anxiety symptoms when paired with
face-to-face or internet-based therapies. In fact, replacing
outpatient patient-therapist sessions with a mobile app
resulted in no significant loss of treatment efficacy (8).
Schizophrenia
Antipsychotic medications can relieve schizophrenic
hallucinations, delusions, and disorganization, but fail to
address its behavioral symptoms. Though psychosocial
interventions (e.g., social skills training, cognitive training,
and education on illness management) can alleviate
behavioral symptoms, these interventions are rarely
integrated into clinical treatment due to limited funding
and adequately trained staff. Mobile apps may present an
opportunity to deliver these services directly to patients,
especially given evidence of little difference between
how schizophrenic patients and healthy controls use
technology (9,10). A systematic review of five studies
© mHealth. All rights reserved.
mHealth, 2018
focused on using smartphone apps for treating symptoms
of schizophrenia demonstrated app retention was 92%, and
approximately 3.95 patient-app interactions took place each
day. Self-reported patient experience survey results revealed
high adherence, positive user experience, and broad-ranging
clinical benefits (11).
What makes them work: characteristics of high-
efficacy apps
It is important to acknowledge the challenges of using apps
for mental health treatment. These challenges can broadly
be divided into the following categories: (I) poor regulation
of quality and privacy; (II) inconsistencies in engagement;
(III) narrow focus on one disorder per app (12,13). To be
effective and address these challenges, mental health apps
must be evidence-based and carefully designed. Developers
should integrate the following four characteristics of high-
efficacy mental health apps.
High patient engagement
Because patients typically use apps on their own time
without clinical oversight, they must be intrinsically
motivated to engage with the app. Evidence from the
literature suggest that patient engagement can be improved
through: (I) real-time engagement; (II) usage reminders; (III)
gamified interactions (14-16).
Simple user interface (UI) and experience
Models of technology-based behavior change emphasize
the importance of simple, intuitive UIs for driving faster
behavior change through reduced cognitive demands. For
patients suffering from depression or anxiety, working
memory is often impaired. Apps serving these population
must be designed to generate a low cognitive load, the total
mental activity imposed on working memory. A simple UI
reduces cognitive load and increases capacity for learning.
Features that reduce cognitive load include: (I) the use of
pictures rather than text; (II) reduced sentence lengths; (III)
inclusive, nonclinical language (14).
Transdiagnostic capabilities
Psychological disorders are highly comorbid; however,
few mental health apps explicitly harness transdiagnostic
methods to treat symptoms shared among disorders. Since
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interventions for comorbid disorders are typically similar
in delivery and content, transdiagnostic apps can increase
patient engagement and treatment efficacy by reducing
the commitment needed to interact with multiple apps for
comorbid disorders (14,17,18).
Self-monitoring features
App-based features that enable users to self-monitor their
mood by periodically reporting their thoughts, behaviors,
and actions can increase emotional self-awareness
(ESA), which has been found to be implicated in anxiety,
depression, and substance abuse (14). Increasing ESA,
defined as the ability to identify and understand one’s own
emotions, has been shown to reduce symptoms of mental
illness and improve coping skills (19-22).
Conclusions
Mobile apps have significant potential to deliver high-
efficacy mental health interventions. Given the global
shortage of psychiatrists and the lack of mental health care
access in rural regions, apps have emerged as a viable tool
to bridge the mental health treatment gap. Technology is
well-poised to transform how mental health treatment is
delivered and accessed, but this transformation requires the
combined mobilization of science, regulation, and design.
Acknowledgements
None.
Footnote
Conflicts of Interest: The author has no conflicts of interest to
declare.
References
1. Anthes E. Mental health: There’s an app for that. Nature
2016;532:20-3.
2. East ML, Havard BC. Mental Health Mobile Apps: From
Infusion to Diffusion in the Mental Health Social System.
JMIR Ment Health 2015;2:e10.
3. Technology and the Future of Mental Health Treatment.
National Institute of Mental Health 2017. Available online:
https://www.nimh.nih.gov/health/topics/technology-and-
the-future-of-mental-health-treatment/index.shtml
© mHealth. All rights reserved. mhealth.amegroups.com
Page 3 of 4
4. Price M, Yuen EK, Goetter EM, et al. mHealth:
a mechanism to deliver more accessible, more
effective mental health care. Clin Psychol Psychother
2014;21:427-36.
5. Yuan S, Ma W, Kanthawala S, et al. Keep Using My
Health Apps: Discover Users Perception of Health and
Fitness Apps with the UTAUT2 Model. Telemed J E
Health 2015;21:735-41.
6. Firth J, Torous J, Nicholas J, et al. The efficacy of
smartphone-based mental health interventions for
depressive symptoms: a meta-analysis of randomized
controlled trials. World Psychiatry 2017;16:287-98.
7. Firth J, Torous J, Nicholas J, et al. Can smartphone mental
health interventions reduce symptoms of anxiety? A meta-
analysis of randomized controlled trials. J Affect Disord
2017;218:15-22.
8. Ly KH, Topooco N, Cederlund H, et al. Smartphone-
Supported versus Full Behavioural Activation for
Depression: A Randomised Controlled Trial. PLoS One
2015;10:e0126559.
9. Ben-Zeev D, Brenner CJ, Begale M, et al. Feasibility,
Acceptability, and Preliminary Efficacy of a Smartphone
Intervention for Schizophrenia. Schizophr Bull
2014;40:1244-53.
10. Abdel-Baki A, Lal S, D-Charron O, et al. Understanding
access and use of technology among youth with first-
episode psychosis to inform the development of
technology-enabled therapeutic interventions. Early Interv
Psychiatry 2017;11:72-6.
11. Firth J, Torous J. Smartphone Apps for Schizophrenia: A
Systematic Review. JMIR Mhealth Uhealth 2015;3:e102.
12. Marley J, Farooq S. Mobile telephone apps in mental
health practice: uses, opportunities and challenges.
BJPsych Bull 2015;39:288-90.
13. Dennison L, Morrison L, Conway G, et al. Opportunities
and Challenges for Smartphone Applications in Supporting
Health Behavior change: Qualitative Study. J Med Internet
Res 2013;15:e86.
14. Bakker D, Kazantzis N, Rickwood D, et al. Mental
Health Smartphone Apps: Review and Evidence-Based
Recommendations for Future Developments. JMIR Ment
Health 2016;3:e7.
15. Chan S, Godwin H, Gonzalez A, et al. Review of Use and
Integration of Mobile Apps Into Psychiatric Treatments.
Curr Psychiatry Rep 2017;19:96.
16. Fleming TM, Bavin L, Stasiak K, et al. Serious Games
and Gamification for Mental Health: Current Status and
Promising Directions. Front Psychiatry 2017;7:215.
mHealth 2018;4:6
Page 4 of 4
17. Johnston L, Titov N, Andrews G, et al. Comorbidity and
Internet-Delivered Transdiagnostic Cognitive Behavioural
Therapy for Anxiety Disorders. Cogn Behav Ther
2013;42:180-92.
18. Rozbroj T, Lyons A, Pitts M, et al. Assessing the
Applicability of E-Therapies for Depression, Anxiety, and
Other Mood Disorders among Lesbians and Gay Men:
Analysis of 24 Web- and Mobile Phone-Based Self-Help
Interventions. J Med Internet Res 2014;16:e166.
19. Heron KE, Smyth JM. Ecological momentary
interventions: Incorporating mobile technology into
psychosocial and health behaviour treatments. Br J Health
Psychol 2010;15:1-39.
doi: 10.21037/mhealth.2018.03.02
Cite this article as: Chandrashekar P. Do mental health mobile
apps work: evidence and recommendations for designing high-
efficacy mental health mobile apps. mHealth 2018;4:6.
© mHealth. All rights reserved. mhealth.amegroups.com
mHealth, 2018
20. Kauer SD, Reid SC, Crooke AH, et al. Self-monitoring
Using Mobile Phones in the Early Stages of Adolescent
Depression: Randomized Controlled Trial. J Med Internet
Res 2012;14:e67.
21. Morris ME, Kathawala Q, Leen TK, et al. Mobile
Therapy: Case Study Evaluations of a Cell Phone
Application for Emotional Self-Awareness. J Med Internet
Res 2010;12:e10.
22. Rickard N, Arjmand HA, Bakker D, et al. Development
of a Mobile Phone App to Support Self-Monitoring
of Emotional Well-Being: A Mental Health Digital
Innovation. JMIR Ment Health 2016;3:e49.
mHealth 2018;4:6